The Call-In: Answers To Questions About Our Business-Driven Health System

Kaiser Health News Editor-in-Chief Elisabeth Rosenthal and NPR Senior Producer Gisele Grayson answered listeners’ questions on NPR’s Weekend Edition Sunday about the Senate GOP’s health care overhaul bill and about the underlying issues that make health care so expensive in this country. Here is a lightly edited transcript of the conversation.

LULU GARCIA-NAVARRO, HOST: This is The Call-In. This week, we asked you for your questions on the Senate Republican health care plan. The future of the bill is uncertain. The Senate has left town for their Fourth of July break without cementing a deal on new legislation amid divisions inside the party and protests from voters. In the studio with me to talk about the bill as it stands now is NPR health editor Gisele Grayson. Hi.

GISELE GRAYSON: Hey there.

GARCIA-NAVARRO: All right, Gisele. Let’s start with a question about the impact the Senate Republican plan could have on adults with disabilities.

KATHERINE PENTEL: My name is Katherine Pentel, and I’m from Kalamazoo, Mich. I have an adult son who is 25 years old and has severe autism and seizure disorder. Will the plan cap Medicaid in such a way that the states will be required to cut back on the services that they provide to adults with disabilities who live in the community? My son is moving into his own apartment and starting an adult life. But I can’t imagine what it will be like if Medicaid is capped, and we no longer receive funds to provide the support staff, since my son cannot live alone. Thank you.

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GARCIA-NAVARRO: Gisele, does she have a reason to be concerned?

GRAYSON: I think she does have reason to be concerned, though not right away and with some caveats. The federal contribution for Medicaid, which both the state and the federal government pay for — federal contributions under this bill go way down over the next 10 years and then some. So states are going to have to make a lot of tough decisions on whether they make up that funding, whether they limit who is eligible for that funding, whether they limit what they pay providers and insurance companies to provide that funding or other ways that they might reduce services.

GARCIA-NAVARRO: So it’s unclear, I guess, at this point what would happen to her in her particular case. But potentially not very good.

GRAYSON: Potentially not very good. The consulting firm Avalere Health gamed out what would happen to funding with disabilities across all 50 states to 2036 — over the next 20 years. And funding for disability across the board is going to go down 24 percent.

GARCIA-NAVARRO: We got several questions about something that hasn’t gotten a lot of coverage but could affect a lot of people. People with employer coverage are asking how they’d be affected.

DUSTIN RILEY: Hello. My name is Dustin Riley. I am from Cincinnati, Ohio. I have insurance currently through my full-time employer. And I’m wondering what may change with the Senate health care bill, as I do have Type 1 diabetes, which is considered a preexisting condition. There are lots of monthly recurring costs not just for the insulin but for the supplies for the insulin pump. And without insurance, I certainly would not be able to afford it at all right now. And I’m wondering how that may change if the Senate health care bill does pass and ends up becoming law. Thank you.

GRAYSON: About half the people in the country get coverage through their employers. The Affordable Care Act went into effect to help people who bought insurance on their own and to help lower-income people. That’s a much smaller fraction of where people get insurance.

That being said, this bill does loosen some consumer protections against insurance companies, imposing lifetime caps and such — or could loosen such protections. But the fact is most large employers offer insurance to keep good workers. So that philosophy is unlikely to change dramatically. A lot will depend on your own company.

I want to say about drug prices, though, there is a glimmer of hope. You know, big businesses feel these high drug prices, too. And there are a lot of initiatives that private companies are taking to try to rein in some of the costs.

GARCIA-NAVARRO: All right. I’d like to bring in Elisabeth Rosenthal to talk about costs. She’s editor-in-chief of Kaiser Health News. And her new book, “An American Sickness,” is about the high cost of health care in the United States. And let me tell you — since I’ve come back to the United States in the last six months, it is shocking if you’ve lived in other countries to see how much health care costs here. Whether we get our insurance from large companies or from the exchanges, premiums are going up across the board. Why?

ELISABETH ROSENTHAL: Well, as some health economists said years ago in an editorial, it’s the prices, stupid. I mean, you know, we pay two to three times more or more than that for some things than people in other developed countries. So what happens? Of course, our premiums and deductibles go up. The insurers aren’t going to eat those costs. We have an inflationary system. And, you know, insurers in our country are for-profit companies. Their primary responsibility is to their shareholders.

GARCIA-NAVARRO: You mention that premiums go up because prices go up. What is driving the high cost of hospital care, for example?

ROSENTHAL: (Laughter).

GARCIA-NAVARRO: I mean, why do people get hundreds of thousands of dollars in bills for staying in a hospital?

ROSENTHAL: Well, the first thing I tell people when they ask me this question is to go into your local hospital and look around. And the marble lobbies, the art, the concierges at the front desk — our hospitals look like not five-star hotels — seven-star hotels. I mean, I think the most stark thing when people go overseas is hospitals in Europe, which deliver really high-quality care. They look like junior high schools. You know, they’re not fancy, but the care is good.

GARCIA-NAVARRO: I assume, as Gisele said, drug prices are a factor, too. What makes them so expensive?

ROSENTHAL: Well, it’s kind of what makes everything so expensive in our country — that we trust the market to solve these things. And it’s a really dysfunctional market. So every other country in the world has a way to negotiate drug prices nationally. We don’t, right? We don’t allow Medicare to negotiate drug prices. We don’t allow foreign competition because we can’t import prescription drugs.

And so what happens? Of course, pharmaceutical manufacturers are for-profit companies. And what have they done in recent years? You know, 20 years ago, when I was a physician, they were mostly run by doctors who had a real commitment to the science and the health and the medicine. Now they’re run by business people.

And what is the business person going to do? They’re going to say, hey, there’s no reason why this old antibiotic should cost 5 cents a pill. Let’s see what happens if we make it $10 a pill. Let’s see if anyone will pay — and because we have no effective way to negotiate that to a reasonable amount. We see these skyrocketing drug prices.

GARCIA-NAVARRO: What some people say, though, is that health care is better than it used to be. We have the technology and the capacity now to know more things about our body, what treatments that we can have to help us live longer. Is that why we are seeing prices rise?

ROSENTHAL: Well, I mean, that’s a reason why the prices of medicine are rising all over the world, right? We’re not the only ones with cool technology. So, sure, you know, when the caller spoke about insulin pumps and monitors, those are all really helpful things for patients. But why do they cost so much more in this country than elsewhere?

You know, echocardiograms, a 30-year-old technology — in our country, we looked at them. You could spend between — if you’re lucky — $1,000 to maybe $7,000 for an echocardiogram. In Japan — I was shocked. I called a Japanese regulator and said, well, how much do you pay for them? It was under $100 ’cause their logic is if you have a great, new technology, sure, you can charge a lot. That’s fine.

But every few years, the price of that has to go down because — just like flat screen TVs. You know, they were really expensive when they first came in. But the price comes down as technology ages. And here we find it stays high or goes up.

GARCIA-NAVARRO: So if I’m a person who wants to keep their medical costs in check, what should I do? The conservative argument is patients should be better shoppers.

ROSENTHAL: Well, I think we all can and should be better shoppers where and when we can be. And I think part of what I recommend is that people start saying to your doctor, OK, why are you referring me to that X-ray center? I want to know which is the cheapest that does a quality X-ray because now that all of us or most of us have high-deductible plans and bigger copays, it behooves us to shop where and when we can to save money.

But I think, much of the time, it’s not a kind of consumer-y thing. You can’t choose when your appendix is going to burst. You can’t choose whether you need surgery. Finally, the big problem is there’s no price transparency in our system — none at all. So I had one example where a vitamin D test cost $7 at one lab and $700 at another in the same state.

GARCIA-NAVARRO: Wow.

ROSENTHAL: So how do I know where I’m being referred to? You don’t until after the fact. And your doctor probably doesn’t know, either.

GARCIA-NAVARRO: We talked about drug prices, doctors and hospitals. Where else is our system faltering?

ROSENTHAL: Well, everyone wants a bad guy. Everyone wants to be able to say, oh, you know, the reason we have such high health costs is because of Pharma. They’re bad. And, you know, the underlying problem is that our health care system has become so commercialized that it’s now driven primarily by business values rather than by health values.

And that’s the essential problem to me because the values of business — those are not the values of health care or medicine. You know, if you’re a doctor or a patient, it’s about infection rates. It’s about talking to your patient. It’s about understanding their illness. It’s an inherently inefficient process at times.

And so if you’re a poor doctor who’s being told by your employer you’ve got to see eight patients an hour, and you’ve got to generate revenue — and the best way to generate revenue isn’t to see patients. It’s to order a lot of tests because that’s more efficient, and it generates revenue. Well, that’s not good health care. That’s bad health care.

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The Call-In: Answers To Questions About Our Business-Driven Health System

July 5, 2017

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